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Existing Facilityew Facility <br />San Joaquin County Environmental Health Department <br />State <br /> Change of Owner Consultation Repairs or Remodel Other <br />License Plate Number <br /> Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br /> Facility Owner Facility Contact Property Owner Contractor Architectl^Billing Party <br />If contractor, indicate type and license number <br />Address <br />EmaiJ <br /> Property Owner Contractor Architect Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPAddressCity <br />EmailPhonePhone <br /> Contractor Facility Contact Property Owner Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br /> OPERATOR/MANAGER <br />Title <br />Linked FA IDAssigned To <br />FeeDate <br /> Check# Cash <br />Rev 07/10/2024 <br />/____________________________ <br />. First Name s p <br />Address . <br />Phone Phone <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Application for <br />Operating Permit <br />ZIP <br />7 <br />ZIP <br />Type of Service <br />Requested <br />Comments <br />virT <br />kj£~o <br />If mobile food truck or <br />pumper truck <br />Payment <br />Received By^J onflrmation # <br />A <br />Phone <br /> Facility Owner <br />City <br />Last name <br />Mvl/ltAKak <br />City . i State <br /> Facility Contact <br />If contractor, indicate 'i" / <br />______ <br />_______________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that atT^X/^j^^roject <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identihWWTthis <br />form. <br />v . • I also certify that I have prepared this application and that the work to be performed will be doqe in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />\j Standards, STATE and FEDERAL laws. . <br />X APPLICANT’S SIGNATURE: _____________< ------------O j-/ f / C d ------------------------------------------------------------ <br />/ PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER Au/iORIZED AGENT <br />Application Form <br />Site Address <br />APN Supervisor District <br />Accepted